Childcare Onboarding

Pre-Application QUestions

Please include as much information as you can

Childcare Center*

Do you or your child live, work, or play in Yamhill County?

Yes

Child Information

Please include as much information as you can

First Name *

Last Name *

Date of Birth *

Age *

Preferred Language *

Does your child have a diagnosed disability?

Yes

Is the child in foster care or in DHS custody?

Yes

Is the child on an Individualized Family Service Plan (IFSP)?

Yes

Does the child have a physical or mental health condition?

Yes

Parent / Guardian Information

Parent / Guardian # 1

Parent / Guardian # 2

Parent / Guardian # 1

First Name *

Last Name *

Email *

Primary Phone Number *

Select the Parent #1's relationship to the child *

Please select the Parent #1's employer *

Does Parent # 1 work full time or part time?

Full Time

Part Time

Does the child live in household with Parent # 1?

Yes

Household Type

1 Parent

2 Parent

Grandparents

Other Caregiver

Total number of individuals living in Parent # 1 household *

Household Status

Living with friend or family

Couch surfing or staying at a different house

Shelter or transitional housing or homeless

Renting

Own Home

Parent / Guardian # 2

First Name *

Last Name *

Email *

Primary Phone Number *

Select the Parent #2's relationship to the child *

Please select the Parent #2's employer *

Does Parent # 2 work full time or part time?

Full Time

Part Time

Does the child live in household with Parent # 2?

Yes

Household Type

1 Parent

2 Parent

Grandparents

Other Caregiver

Total number of individuals living in Parent # 2 household *

Household Status

Living with friend or family

Couch surfing or staying at a different house

Shelter or transitional housing or homeless

Renting

Own Home

Additional Information

Please select the most accurate options for each question

WIC

SNAP

TANIF

SSI/SSD or VA Compensations

Is any member of the child's household(s) currently pregnant or expecting a child?

Yes

Not sure

Prefer not to say

Is the child or any member of the child's household(s) in (or has been in) the custody of DHS or foster care?

Yes

Not sure

Prefer not to say

Is any member of the child's household(s) working (or has worked) in agriculture or on farms?

Yes

Not sure

Prefer not to say

Does the child have parents that are separated or divorced?

Yes

Not sure

Prefer not to say

Is or has any member of the child's household(s) using or in recovery (past or present) from alcohol or other drugs/substances?

Yes

Not sure

Prefer not to say

Is the child or any member of the child's family(s) depressed or mentally ill (or has been)?

Yes

Not sure

Prefer not to say

Has any member of the child's household(s) been incarcerated or in jail for an extended period of time?

Yes

Not sure

Prefer not to say

Has the child or any member of the child's household(s) experienced domestic violence, inappropriate touching, stalking, or sexual assault?

Yes

Not sure

Prefer not to say

Does the child or any member of the child's household(s) identify as medically fragile or has/had a disabling condition?

Yes

Not sure

Prefer not to say

Is any member of the child's household(s) currently attend school or trade training program?

Yes

Not sure

Prefer not to say

Has any member of the child's household(s) not graduated from high school or never obtained a GED?

(adult household members only)

Yes

Not sure

Prefer not to say

Has the child or any member of the child's household(s) experience, or is concerned about experiencing, physical, or emotional harm?

Yes

Not sure

Prefer not to say

Has the child or any member of the child's household(s) felt or feel they had to wear dirty clothes and/or didn't or doesn't feel cared for?

Yes

Not sure

Prefer not to say

Has the child or any member of the child's household(s) ever felt or feel they didn't or don't have enough to eat?

Yes

Not sure

Prefer not to say

Has the child or any member of the child's household(s) been raised by a single parent, teen, or young parent?

Yes

Not sure

Prefer not to say

Would you like someone to contact you and talk about supports and services for:

Housing & Shelter
Food
Clothing
Depression or Anxiety
Parent Support
Alcohol or Drug Support
School & Education Support
Legal Help
Employment & Job Seeking Help
Behavioral Health
Medical Care
Pregnancy Care
Other

Yes

Project OASIS

Child Name

Pre-Application QUestions

Child Information

Parent / Guardian Information

Parent / Guardian # 1

Parent / Guardian # 2

Additional Information